BOSTON COLLEGE UNIVERSITY HEALTH SERVICES
TUBERCULOSIS (TB) SCREENING/TESTING FORM
Date:
Name:
Last
First
Eagle ID#:
Date of Birth:
Cell Phone:
Email:
Please refer to this list of countries below when responding to questions #4 and #5
Afghanistan
Congo
Iran (Islamic Republic of)
Namibia
Solomon Islands
Algeria
Côte d'Ivoire
Iraq
Nauru
Somalia South Africa
Angola
Democratic People's
Kazakhstan
Nepal
South Sudan
Anguilla
Republic of Korea
Kenya
Nicaragua
Sri Lanka
Argentina
Democratic Republic of the Kiribati
Niger
Sudan
Armenia
Congo
Kuwait
Nigeria
Suriname
Azerbaijan
Djibouti
Kyrgyzstan
Northern Mariana Islands
Swaziland
Bangladesh
Dominican Republic
Lao People's Democratic
Pakistan
Tajikistan
Belarus
Ecuador
Republic
Palau
Thailand
Belize
El Salvador
Latvia
Panama
Timor-Leste
Benin
Equatorial Guinea
Lesotho
Papua New Guinea
Togo
Bhutan
Eritrea
Liberia
Paraguay
Trinidad and Tobago
Bolivia (Plurinational State
Estonia
Libya
Peru
Tunisia
of)
Ethiopia
Lithuania
Philippines
Turkmenistan
Bosnia and Herzegovina
Fiji
Madagascar
Poland
Tuvalu
Botswana
French Polynesia
Malawi
Portugal
Uganda
Brazil
Gabon
Malaysia
Qatar
Ukraine
Brunei Darussalam
Gambia
Maldives
Republic of Korea
United Republic of
Bulgaria
Georgia
Mali
Republic of Moldova
Tanzania
Burkina Faso
Ghana
Marshall Islands
Romania
Uruguay
Burundi
Greenland
Mauritania
Russian Federation
Uzbekistan
Cabo Verde
Guam
Mauritius
Rwanda
Vanuatu
Cambodia
Guatemala
Mexico
Saint Vincent and the
Venezuela (Bolivarian
Cameroon
Guinea
Micronesia (Federated States
Grenadines
Republic of)
Central African Republic
Guinea-Bissau
of)
Sao Tome and Principe
Viet Nam
Chad
Guyana
Mongolia
Senegal
Yemen
China
Haiti
Montenegro
Serbia
Zambia
China, Hong Kong SAR
Honduras
Morocco
Seychelles
Zimbabwe
China, Macao SAR
India
Mozambique
Sierra Leone
Colombia
Indonesia
Myanmar
Singapore
Comoros
Source: World Health Organization Global Health Observatory, Tuberculosis Incidence 2014. Countries and territories with incidence rates of ≥ 20 cases
per 100,000 population. For future updates, refer to http://www.who.int/tb/country/en/.
1. Did you ever receive a BCG vaccine as a child?
2. Have you ever had close contact with persons known or suspected to have active TB disease?
3. Have you ever had a history of a positive PPD skin test?
4. Were you born in one of the countries or territories listed above that have a high incidence of active TB
disease? (If yes, please CIRCLE the country)
5. Are you a recent arrival (<5 years) from one of the high prevalence areas listed above?
If YES please indicate date of arrival:
/
/
6. Have you had frequent or prolonged visits (for more than one month) to one or more of the countries
or territories listed above with a high prevalence of TB disease? (If yes, CHECK the country/countries)
7. Have you been a health care worker, volunteer, resident and/or employee of high-risk congregate
settings or served clients who are at increased risk of active TB disease (e.g., correctional facilities, longterm care facilities, homeless shelter, substance abuse treatment, rehabilitation facility)?
8. Have you ever been a member of any of the following groups that may have an increased incidence of
latent M. tuberculosis infection or active TB disease – medically underserved, low income or abusing drugs
or alcohol?




Yes
Yes
Yes
Yes




No
No
No
No
Unsure



 Yes
 No 
 Yes
 No 
 Yes
 No 
 Yes
 No 
If the answer is YES to any of the above questions, Boston College requires that you receive TB testing as soon
as possible but at least prior to the start of the semester. Have your physician complete and return the
Tuberculosis (TB) Risk Assessment on pages 2 and 3 with additional testing and/or documentation as needed.
If the answer to all of the above questions is NO, no further testing is required (no need to complete page
2 & 3). Return form to: Boston College University Health Services, Cushing Hall Rm. 117, 140
Commonwealth Ave, Chestnut Hill, MA 02467)
Page 1 of 3
Rev 4/2016
BOSTON COLLEGE UNIVERSITY HEALTH SERVICES
TUBERCULOSIS (TB) SCREENING/TESTING FORM
Date:
Name:
Last
First
Eagle ID#:
Date of Birth:
Cell Phone:
Email:
TUBERCULOSIS (TB) RISK ASSESSMENT (to be completed by health care provider)
Clinicians should review and verify information on the TB Screening Form. Persons answering YES to any of the questions are candidates for
either Mantoux tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA), unless a previous positive test is documented.
History of a positive TB skin test or IGRA blood test?
No
Yes
(if Yes, and received previous treatment complete
the TB Symptom Check and the Medication Section)
History of BCG vaccination? (If yes, consider IGRA if possible.)
Yes
No
1. TB Symptom Check
Does the student have signs or symptoms of active pulmonary tuberculosis disease? Yes
No
If No, proceed to 2 or 3
If yes, check below:
 Cough (especially if lasting for 2-3 weeks or longer) with or without sputum production
 Coughing up blood (hemoptysis)
 Chest pain
 Loss of appetite
 Unexplained weight loss, unusual weakness or extreme fatigue
 Night sweats
 Fever
Proceed with additional evaluation to exclude active tuberculosis disease including tuberculin skin testing, chest x-ray, and sputum
evaluation as indicated.
2. Tuberculin Skin Test (TST)
(TST result should be recorded as actual millimeters (mm) of induration, transverse diameter; if no induration, write “0”. The TST
interpretation should be based on mm of induration as well as risk factors.)**
Date Given:
Result:
_/
_/
M D
Y
Date Read:
_/
M
/
D
Y
mm of induration **Interpretation (please refer to interpretation guidelines): positive
negative
(If positive Chest X-Ray Required see pg 3 of 3)
**Interpretation guidelines
>5 mm is positive:
 Recent close contacts of an individual with infectious TB
 persons with fibrotic changes on a prior chest x-ray, consistent with past TB disease
 organ transplant recipients and other immunosuppressed persons (including receiving equivalent of >15 mg/d of prednisone for 1 month or
more)
 HIV-infected persons
>10 mm is positive:
 recent arrivals to the U.S. (<5 years) from high prevalence areas or who resided in one for a significant* amount of time
 injection drug users
 mycobacteriology laboratory personnel
 residents, employees, or volunteers in high-risk congregate settings for example prisons, long term care facilities, health care facilities,
homeless shelters, residential facilities for patients with HIV/AIDS
 persons with medical conditions that increase the risk of progression to TB disease including silicosis, diabetes mellitus, chronic renal
failure, certain types of cancer/hematologic disorders (leukemias and lymphomas, cancers of the head, neck, or lung), gastrectomy or
jejunoileal bypass and weight loss of at least 10% below ideal body weight.
 Children < than 4 years of age or infants, children and adolescents exposed to adults at high-risk
>15 mm is positive:
 persons with no known risk factors for TB who, except for certain testing programs required by law or regulation, would otherwise not be
tested.
* The significance of the travel exposure should be discussed with a health care provider and evaluated.
Health Care Provider’s Signature:
(Continue on page 3)
Page 2 of 3
Rev 4/2016
BOSTON COLLEGE UNIVERSITY HEALTH SERVICES
TUBERCULOSIS (TB) SCREENING/TESTING FORM
Date:
Name:
Last
First
Eagle ID#:
Date of Birth:
Cell Phone:
Email:
3. Interferon Gamma Release Assay (IGRA)
Date Obtained:
/
M
Result: negative
/
D
Y
positive
(specify method)
QFT-GIT
indeterminate
borderline
T-Spot
other
(T-Spot only)
4. Chest x-ray: (Required if TST or IGRA is POSITIVE)
Date of chest x-ray:
_/
M
_/
D
Result: normal
abnormal
Y
TUBERCULOSIS (TB) RISK ASSESSMENT Management of Positive TST or IGRA
All students with a positive TST or IGRA with no signs of active disease on chest x-ray should receive a recommendation to be treated for latent
TB with appropriate medication. However, students in the following groups are at increased risk of progression from LTBI to TB disease and
should be prioritized to begin treatment as soon as possible.
 Infected with HIV
 Recently infected with M. tuberculosis (within the past 2 years)
 History of untreated or inadequately treated TB disease, including persons with fibrotic changes on chest radiograph consistent with prior TB
disease
 Receiving immunosuppressive therapy such as tumor necrosis factor-alpha (TNF) antagonists, systemic corticosteroids equivalent to/greater
than 15 mg of prednisone per day, or immunosuppressive drug therapy following organ transplantation
 Diagnosed with silicosis, diabetes mellitus, chronic renal failure, leukemia, or cancer of the head, neck, or lung
 Have had a gastrectomy or jejunoileal bypass
 Weigh less than 90% of their ideal body weight
 Cigarette smokers and persons who abuse drugs and/or alcohol
••Populations defined locally as having an increased incidence of disease due to M. tuberculosis, including medically underserved, low income
populations
MEDICATION SECTION:
Was the patient educated and counseled on latent tuberculosis and advised to take medication because of the positive
results? NO
YES
Patient agrees to receive treatment
If yes, what medication(s) was prescribed?
Date Started:
/
/
Date Ended:
_/
/
Patient declines treatment at this time
HEALTH CARE PROVIDER
Name
Signature
Address
Phone (
)
Please Return Form(s) to:
BOSTON COLLEGE UNIVERSITY HEALTH SERVICES
CUSHING HALL RM 117
140 COMMONWEALTH AVE
CHESTNUT HILL, MA 02467
Page 3 of 3
Rev 4/2016